PRINTED: 08/29/2018 DEPARTMENT OF HEALTH AND HUMAN … · 2020. 3. 24. · HEALTHWIN 20531 DARDEN...

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

08/29/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION

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B. WING

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COMPLETED

NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

(X4) ID

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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COMPLETION

DATECROSS-REFERENCED TO THE APPROPRIATE

SOUTH BEND, IN 46637

155153 08/06/2018

HEALTHWIN

20531 DARDEN RD

00

F 0000

Bldg. 00

This visit was for a Recertification and State

Licensure Survey. This visit included the

Investigation of Complaint IN00269561.

Complaint IN00269561 - Substantiated.

Federal/State deficiencies related to the

allegations are cited at F744.

Survey dates: July 31, August 1, 2, 3, & 6, 2018

Facility number: 000073

Provider number: 155153

AIM number: 100288820

Census Bed Type:

SNF/NF: 122

SNF: 9

Total: 131

Census Payor Type:

Medicare: 21

Medicaid: 81

Other: 27

Total: 131

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality Review was completed on August 14,

2018.

F 0000 This plan of correction also

represents the facility's

allegations of compliance. The

following combined plan of

correction and allegations of

compliance is submitted solely

because it is required by law

and is not an admission to any

of the alleged deficiencies or

violations. Furthermore, none

of the actions taken in this plan

of correction are an admission

that additional steps should

have or could have been taken

by the facility to prevent the

alleged deficiency. These steps

are only included because a

plan of correction is required

by law.

The facility was in compliance

with all licensure and

certification requirements at

the time of the survey and

disputes that any alleged

deficiency or violation existed.

483.21(b)(1)

Develop/Implement Comprehensive Care Plan

§483.21(b) Comprehensive Care Plans

§483.21(b)(1) The facility must develop and

implement a comprehensive person-centered

care plan for each resident, consistent with

F 0656

SS=D

Bldg. 00

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 03B411 Facility ID: 000073

TITLE

If continuation sheet Page 1 of 22

(X6) DATE




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the resident rights set forth at §483.10(c)(2)

and §483.10(c)(3), that includes measurable

objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

comprehensive assessment. The

comprehensive care plan must describe the

following -

(i) The services that are to be furnished to

attain or maintain the resident's highest

practicable physical, mental, and

psychosocial well-being as required under

§483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be

required under §483.24, §483.25 or §483.40

but are not provided due to the resident's

exercise of rights under §483.10, including

the right to refuse treatment under §483.10(c)

(6).

(iii) Any specialized services or specialized

rehabilitative services the nursing facility will

provide as a result of PASARR

recommendations. If a facility disagrees with

the findings of the PASARR, it must indicate

its rationale in the resident's medical record.

(iv)In consultation with the resident and the

resident's representative(s)-

(A) The resident's goals for admission and

desired outcomes.

(B) The resident's preference and potential for

future discharge. Facilities must document

whether the resident's desire to return to the

community was assessed and any referrals

to local contact agencies and/or other

appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive

care plan, as appropriate, in accordance with

the requirements set forth in paragraph (c) of

this section.

Based on interview and record review, the facility F 0656 Healthwin requests 09/05/2018 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 03B411 Facility ID: 000073 If continuation sheet Page 2 of 22




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155153 08/06/2018

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failed to ensure appropriate, complete and

individualized care plans were developed related

to targeted behaviors (Residents C, D, & E),

hospice care (Resident 9), and dialysis care

(Resident 106) for 5 of 25 residents whose care

plans were reviewed.

Findings Include:

1. A clinical record review was conducted on

08/02/18, at 2:45 PM, for Resident 9. Her

diagnoses included, but were not limited to: heart

failure, chronic kidney disease stage 3, gout,

insomnia, anxiety, hypertension, diaphragm

hernia, weakness, and atrial fibrillation.

The MDS (Minimum Data Set) assessment, dated

05/09/18, indicated a BIMS (Brief Interview for

Mental Status) score of 15, cognitively intact. A

significant change MDS was in process, but not

completed at time of review.

A hospice order was in place and indicated she

was started on hospice services as of 07/20/18.

The diagnosis was indicated as congestive heart

failure.

A hospice care plan was in place, but did not

contain the provision of ADL (Activities of Daily

Living) care, advance directive information,

hospice contact and coordination of care.

No hospice binder was found on the unit.

Scanned hospice documents were present in the

chart, but did not have contact information for the

hospice provider, or when to contact.

During an interview, on 08/03/18 at 8:57 AM, MR

(Medical Records) employee indicated there was

not a hospice book kept on unit, as the facility

consideration for a desk review

for all citations.

Healthwin will continue to ensure

that comprehensive care plans are

developed and implemented for all

residents.

- What corrective action(s)

will be accomplished for those

residents found to have been

affected by the deficient

practice;

CMS regulations and Critical

Element Pathways for Hospice,

Dialysis, and Behavioral/Emotional

Status were reviewed. Care plans

for residents 106 and 9 were

updated to include required

Hospice and Dialysis information.

Care plans for residents C, D, and

E were reviewed and updated to

reflect appropriate focus, goals,

and interventions for Dementia

and/or Behavioral Health

Diagnosis.

- How other residents

having the potential to be

affected by the same deficient

practice will be identified and

what corrective action(s) will

be taken;

Any resident receiving Hospice or

Dialysis services as well as

residents displaying behaviors or

on psychotherapeutic medications

have the potential to be affected.

- What measures will be put

into place and what systemic





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155153 08/06/2018

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does not use them. All hospice documents were

expected to be scanned into the chart.

During an interview, on 08/06/18 at 10:08 AM, the

DON (Director of Nursing) indicated she was not

aware of the hospice care plan requirements and

the current care plan in place did not contain the

appropriate information.

2. During an interview, on 08/01/18 at 9:32 AM,

Resident 106 indicated the facility does assess

their dialysis access site as appropriate, has

pre-visit vitals completed, and utilized a

communication binder.

A clinical record review was conducted on

08/02/18, at 9:09 AM, for Resident 106 and

indicated an admission date of 06/07/18. His

diagnoses included, but were not limited to: adult

failure to thrive, superventricular tachycardia, end

stage renal disease, diabetes, hypertension,

weakness, sleep apnea, and anemia.



Mental Status) score of 15, cognitively intact.

Dialysis was indicated as active.

A care plan was in place related to dialysis care,

but did not contain specific type, location,

transportation, and goals/interventions for

dialysis care, contact information for emergencies,

complication monitoring, or advance directive

information.

A physician order was in place. The

documentation indicated site care and assessment

completed as appropriate. The dialysis

communication book was in place with

appropriate information.

changes will be made to

ensure that the deficient

practice does not recur;

IDT will be in-serviced on Care

Plan Policy and Procedure. IDT

will also review the CMS

regulations for Comprehensive

Care Planning and Critical

Element Pathway relating to

Behavioral/Emotional Status,

Dementia, Dialysis, and Hospice.

Baseline Care Plans will continue

to be completed within 48 hours.

Comprehensive Care Plans will be

initiated within 48 hours.

.

- How the corrective

action(s) will be monitored to

ensure the deficient practice

will not recur, i.e., what quality

assurance program will be put

into place;

DON, CCO, or designee will audit

baseline care plans to ensure they

are thoroughly completed and

comprehensive care plans are

initiated within 48 hours for new

admits weekly x 4 then 10

monthly x5. If any concerns are

noted the audits will continue for

an additional 6 months.

- By what date the systemic

changes for each deficiency

will be completed. After

submitting an acceptable Plan





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During an interview, on 08/06/18 at 10:08 AM, the

DON (Director of Nursing) indicated she was not

aware of the required care plan information and it

would be corrected.3. The clinical record for

Resident D was reviewed on 8/2/18 at 1:35 P.M.

The diagnoses included, but were not limited to

dementia, anxiety and depression.

The admission MDS (Minimum Data Set)

assessment, dated 6/6/18, indicated Resident D

had a BIMS (Brief Interview of Mental Status)

score of 5, severe cognitive impairment and was

receiving antidepressant and antianxiety

medications with no GDR (gradual dose

reduction) dates.

A care plan, revised on 6/8/18, indicated Resident

D was at risk for decline in mood due to diagnosis

of depression and anxiety and she was taking

both antidepressants and antianxiety medications.

There were not no targeted behaviors or

individualized interventions present for anxiety

symptoms.

The Medication Review Report, dated 8/6/18,

indicated Resident D had an order for Ativan

(antianxiety) 0.5 mg (milligrams) every eight (8)

hours for anxiety with a start date of 8/28/17 and

Lexapro 10 mg at bedtime for depression with a

start date of 3/21/17.

The Documentation Survey Report, dated July

2018, indicated Resident D had behaviors of being

combative during care, searching for family

members and wandering on and off the unit with

no documentation of interventions that were

attempted.

of Correction, if it is

determined that the correction

will not be completed by the

date previously submitted, The

Division needs to be contacted

as soon as possible. The

facility will need to submit an

amended plan of correction

with the updated plan of

correction date.

9/5/18





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During an interview, on 8/6/18 at 9:53 A.M., the

DON (Director of Nursing) indicated the

depression and anxiety should be in separate

plans of care and plan of care should contain

targeted behaviors and individualized

interventions.

4. The clinical record for Resident E was reviewed

on 8/3/18 at 11:28 A.M. The diagnoses included,

but were not limited to, dementia, anxiety and

depression.


assessment, dated 6/5/18, indicated Resident E


score of 12, moderate cognitive impairment, and

was receiving antipsychotic and antidepressant

medication.


indicated Resident E had an order for Seroquel 25

mg (milligrams) at bedtime related to Parkinson's

Disease.

A care plan, dated 6/18/18, indicated Resident E

uses antipsychotic medications related to the

disease process of Parkinson's.

There were no targeted behaviors or

individualized interventions present for the use of

antipsychotic medications.

During an interview, on 8/6/18 at 12:00 P.M., the


antipsychotic care plan should include targeted

behavior with individualized interventions and

appropriate diagnosis.5. A clinical record review

was conducted, on 8/2/18 at 2:04 P.M., for

Resident C and indicated she was admitted on

5/18/18. Her diagnoses included, but were not





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155153 08/06/2018

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20531 DARDEN RD

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limited to Alzheimer's disease, delusional

disorders, depressive disorder, vascular dementia

with behavioral disturbance.



Mental Status) score of 3, severe cognitive

impairment and a PHQ-9 (Patient Health

Questionnaire) assessment indicated a score of 0,

minimal or no depression.

The care plan indicated a care plan, undated, for

mood. The care plan did not include specific

behaviors related to the use of quetiapine

fumarate, an antipsychotic medication or

mirtazapine, an antidepressant. The interventions

indicated to administer medications as ordered,

observe/document for side effects and

effectiveness.

A hospital discharge summary, dated 5/16/16,

indicated she had a psychiatric hospital stay due

to paranoid delusions, yelling at staff and other

residents at a previous facility prior to admission.

During an interview, on 8/3//18 at 4:29 P.M., the

DON (Director of Nursing) indicated Resident C

had not been having any behaviors and was not

aware of what specific behaviors she was having

prior to admission. The DON indicated she should

have been monitored for behaviors that the

psychiatric hospital indicated she was put on the

quetiapine and mirtazapine for and she should

have had a care plan indicating those behaviors.

A policy was provided by the DON on 8/6/18 at

9:30 A.M., titled, "...Care Plan-Comprehension",

no date, and indicated the policy was the one

currently being used by the facility. The policy

indicated "...It is the policy of this facility to





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develop and implement a comprehensive

person-centered care plan for each resident ,

consistent with resident rights, that includes

measurable objectives and timeframes to meet a

resident's medical, nursing, and mental and

psychosocial needs that are identified in the

resident's comprehensive assessment...."

3.1-35(a)

483.40(b)(3)

Treatment/Service for Dementia

§483.40(b)(3) A resident who displays or is

diagnosed with dementia, receives the

appropriate treatment and services to attain

or maintain his or her highest practicable

physical, mental, and psychosocial

well-being.

F 0744

SS=D

Bldg. 00

Based on record review and interview, the facility

failed to meet the needs of a resident with the

diagnosis of severe vascular dementia in 1 of 3

residents reviewed for dementia care. (Resident B)

Finding includes:

The clinical record for Resident B was reviewed


but were not limited to, vascular dementia and

multiple right posterior cerebral artery

cerebrovascular accident.


assessment, dated 7/19/18, indicated Resident B


score of 6, severe cognitive impairment and had

displayed behaviors that significantly interfered

with her ADLs (activities of daily living).

There was no care plan available for diagnosis of

dementia.

F 0744 Healthwin requests


for all citations.


that behavioral health care plans

and tracking are developed and

implemented for all residents to

maintain the highest level of

psychosocial well-being.

- what corrective action(s)




practice;

CMS regulation and Dementia

Care and Behavioral/Emotional

Status Critical Element Pathway

reviewed. Resident B was

discharged 7/20/18. Social

Service and Nursing departments

began reviewing all care plans for

residents with a behavioral health

09/05/2018 12:00:00AM





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A care plan, no date, indicated Resident B used

anti-anxiety medication related to adjustment

issues and anxiety disorder that included the

following interventions: educate

resident/family/caregivers about risks, benefits

and the side effects and/or toxic symptoms of

anti-anxiety medication drugs being given, give

anti-anxiety medications as ordered and

observe/document side effects and effectiveness,

and monitor for safety.

A care plan, no date, indicated Resident B resisted

care and noncompliant with care that included,

but was not limited to, the following interventions:

assess resident's understanding of situation,

coping skills and support system, inform resident

of risks of noncompliance, and involve resident in

setting goals.

A care plan, no date, indicated Resident B used

antidepressant medication related to depression

and anxiety that included the following

interventions: give antidepressant medication as

ordered ph physician and observe/document side

effects and effectiveness and

observe/document/report to physician as needed

ongoing signs and symptoms of depression

unaltered by antidepressant medications.


individualized interventions present in the plan of

care related to depression.

There was no documentation of behavior tracking

available to indicate the interventions that were

attempted and the effectiveness of interventions

for behaviors.

The Discharge Summary from local hospital, dated

diagnosis or dementia diagnosis.

Care plans and behavior tracking

are being updated to reflect

individualized goals and

interventions for maintaining the

highest level of well-being.

- how other residents having

the potential to be affected by

the same deficient practice will

be identified and what

corrective action(s) will be

taken;

All residents who may have a

behavioral health diagnosis or

dementia diagnosis

what measures will be put into

place and what systemic




All staff will be provided the new

Dementia Care Policy. Social

Services and Nursing

administration will ensure behavior

tracking tasks are entered into

POC. Nursing aides will be

in-serviced on documenting

behaviors for tracking purposes.

Baseline Care Plans will continue

to be completed within 48 hours.

Comprehensive Care Plans will be

initiated within 48 hours.

- how the corrective








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155153 08/06/2018

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7/12/18, indicated Resident B had severe vascular

dementia for years, lived at home with her son,

and was found at home with profound left sided

weakness. She was evaluated by therapy and it

was recommended that she receive some rehab for

her deficits.

The History & Physical from the facility, dated

7/13/18, indicated Resident B had a history of

severe dementia.

The Order Summary Report, dated 7/13/18,

indicated Resident B had a diagnosis of vascular

dementia without behavioral disturbances and

had an order for rivastigmine patch for dementia.

The Medication Administration Record, dated

7/1/18 through 7/31/18, indicated Resident B had

an order for Trazadone 50 mg (milligrams) at

bedtime for anxiety/depression with start date of

7/20/18 and Ativan 0.5 mg every eight (8) hours

for anxiety with start date of 7/15/18.

A Progress Note, dated 7/13/18 at 12:33 P.M.,

indicated Resident B continued to express desire

to return home and was belligerent in therapy per

therapy personnel stating she wanted to go home.


indicated a wander guard was applied to Resident

B's wheelchair.


indicated the facility had reassured Resident B's

daughter that they would call the resident's son if

she became belligerent or hard to handle.


indicated the physician was notified of resident's

severe anxiety and increase in behaviors and a


into place; and


the baseline care plans to ensure

they are thoroughly completed and

comprehensive care plans are

initiated within 48 hours for new

admits weekly x 4 then 10

monthly x5. If any concerns are

noted the audits will continue for

an additional 6 months. DON,

CCO, or designee will ensure that

behavior tracking is reviewed

weekly during behavior

management meetings.

- by what date the systemic













correction date.

9/5/18





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new order for lorazepam (Ativan) 0.5 mg every 8

hours as needed for anxiety was received.


indicated Resident B had became agitated and

verbally abusive to staff because she could not

go home and staff tried to explain to her why she

was at the facility.


indicated Resident B had underlying dementia and

had increased anxiety since coming to the facility

and was started on lorazepam 0.5 mg.


indicated Resident B had asked nursing staff why

she placed in the facility and the nurse told the

resident was placed in the facility by her

physician, which upset the resident.


indicated Social Services had discussed with

Resident B's family the possibility of a Dementia

Unit due to dementia with sundowners.



Resident B if she felt safe and the resident

indicated she was being held against her will and

she did not want to hurt herself but she would if

she didn't get out of the facility.

A Progress Note, dated 7/19/18 at 12:15 P.M.

indicated Social Services had spoke with

resident's family about either finding another

placement in a Dementia Unit or sending the

resident to the a psychiatric hospital due to the

comments she was making.






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indicated another facility was willing to accept the

facility on 7/23/18.


indicated Social Services had made referral to local

psychiatric hospital.


indicated Social Services had notified family

regarding the other facility would potentially be

willing to accept resident and that a referral had

been made to the local psychiatric hospital. The

family member indicated she was not happy about

the referral to a psychiatric unit as she felt the

resident did not need a psychiatric unit.


indicated Resident B's daughter called the facility

and asked if she could stay at the facility with her

mother until she was discharged to another

facility and she felt her mom didn't need to go to

psychiatric unit. The facility felt since the resident

was discharging to a Dementia Unit that she still

needed a psychiatric evaluation and the daughter

was upset.


indicated the facility felt the local psychiatric

hospital would take to long to make a decision on

excepting Resident B and it was decided to she

resident to local ER (emergency room) for an

emergency psychiatric evaluation.


indicated Social Services had spoke with family

and indicated if the local hospital felt that

Resident B was suicidal they would admit her to

local psychiatric hospital and if they didn't the

hospital would send her back to the facility.





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The ER Physician Note, dated 7/19/18, indicated

Resident B had a past medical history of dementia

and anxiety and facility had sent her to ER for a

psychiatric evaluation because the resident had

expressed the she wanted to die and that she was

going to step out in front of traffic. The resident's

son and daughter-in-law were present for the

evaluation at the hospital and Resident B was

very fixated on getting back home. She was

transferred back the facility.


indicated Resident B was still making statements

of wanting to go home and she would "break a

window if I have to".


indicated Resident B was attempting to leave floor

heading towards elevator stating "If I can's leave

here I'll just go kill myself."


indicated a new order for Trazadone (sedative and

antidepressant) 50 mg was received

There was no documentation of any interventions

that were attempted prior to Trazadone being

given.

A Progress Note, dated 7/20/18 at 10:40 A.M.,


daughter about admitting Resident B to a

psychiatric hospital and that a psychiatric

evaluation was not completed at the hospital.


Resident B was transferred to local psychiatric

hospital.






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155153 08/06/2018

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indicated Social Services had spoke with local

psychiatric hospital and that Resident B was

doing poorly, stating she wants to die because

she could not go home.


CCO (Chief Clinical Officer) indicated a plan of

care for dementia with behaviors should have

developed and implemented with targeted

behaviors and interventions for Resident B upon

admission.

On 8/6/18 at 11:45 A.M., a policy for Dementia

Care was requested and the DON (Director of

Nursing) indicated no policy was available.

This Federal tag relates to complaint IN00269561.

3.1-37(a)

483.45(c)(3)(e)(1)-(5)

Free from Unnec Psychotropic Meds/PRN

Use

§483.45(e) Psychotropic Drugs.

§483.45(c)(3) A psychotropic drug is any

drug that affects brain activities associated

with mental processes and behavior. These

drugs include, but are not limited to, drugs in

the following categories:

(i) Anti-psychotic;

(ii) Anti-depressant;

(iii) Anti-anxiety; and

(iv) Hypnotic

Based on a comprehensive assessment of a

resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used

psychotropic drugs are not given these drugs

unless the medication is necessary to treat a

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155153 08/06/2018

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20531 DARDEN RD

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specific condition as diagnosed and

documented in the clinical record;

§483.45(e)(2) Residents who use

psychotropic drugs receive gradual dose

reductions, and behavioral interventions,

unless clinically contraindicated, in an effort

to discontinue these drugs;

§483.45(e)(3) Residents do not receive

psychotropic drugs pursuant to a PRN order

unless that medication is necessary to treat

a diagnosed specific condition that is

documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic

drugs are limited to 14 days. Except as

provided in §483.45(e)(5), if the attending

physician or prescribing practitioner believes

that it is appropriate for the PRN order to be

extended beyond 14 days, he or she should

document their rationale in the resident's

medical record and indicate the duration for

the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic

drugs are limited to 14 days and cannot be

renewed unless the attending physician or

prescribing practitioner evaluates the resident

for the appropriateness of that medication.

Based on interview and record review, the facility

failed to ensure individualized behaviors and

interventions were monitored and documented

related to antidepressant, antipsychotic and

antianxiety use (Residents C, D, E) for 3 of 5

residents reviewed for unnecessary medications.

Finding Include:

1. A clinical record review was conducted, on



for all citations.


that residents remain free from

unnecessary medications and

individualized interventions are

provided to reduce behaviors and

maintain the highest level of

psychosocial well-being.

09/05/2018 12:00:00AM





08/29/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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155153 08/06/2018

HEALTHWIN

20531 DARDEN RD

00

8/2/18 at 2:04 P.M., for Resident C and indicated

she was admitted on 5/18/18. Her diagnoses

included, but were not limited to Alzheimer's

disease, delusional disorders, depressive disorder,

vascular dementia with behavioral disturbance.



Mental Status) score of 3, severe cognitive

impairment and a PHQ-9 (Patient Health

Questionnaire) assessment indicated a score of 0,

minimal or no depression. The MDS indicated she

received 7 days of an antidepressant and

antipsychotic.

Medication orders included, but were not limited

to quetiapine fumarate 50 mg daily at bedtime, an

antipsychotic, and mirtazapine 15 mg daily at

bedtime, an antidepressant.

The care plan indicated a care plan, undated, for

mood. The care plan did not indicate specific

behaviors related to the use of quetiapine

fumarate or mirtazapine. The interventions

indicated to administer medications as ordered

and observe and document for side effects and

effectiveness.

There were no behavior monitoring sheets

available for specific behaviors related to the use

of quetiapine and mirtazapine.

A hospital discharge summary, dated 5/16/16,

indicated she had a psychiatric hospital stay due

to paranoid delusions, yelling at staff and other

residents at a previous facility prior to admission.

During an interview, on 8/3//18 at 4:29 P.M., the

DON (Director of Nurses) indicated Resident C

had not been having any behaviors and was not





practice;

CMS regulations and Critical

Element Pathway for Unnecessary

Medications were reviewed. Care

plans for residents C, D, and E

were updated to reflect behaviors

with personalized

non-pharmacological interventions

as well as behavior tracking tasks

were updated in the electronic

health record. Medications for

residents C & D were reduced.






be taken;

Residents who have displayed or

have a history of behaviors and are

on psychotropic medications.






Residents on psychotropic

medications will be monitored for

behaviors and efficacy of

medications during behavior

management meetings and as

needed. Non-pharmacological

interventions will be monitored for





08/29/2018PRINTED:

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OMB NO. 0938-039




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155153 08/06/2018

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aware of what specific behaviors she was having

prior to admission. The DON indicated she should

have been monitored for behaviors that the

psychiatric hospital indicated she was put on the

quetiapine and mirtazapine for and she should

have had a care plan indicating those behaviors.

2. The clinical record for Resident D was reviewed

on 8/2/18 at 1:35 P.M. The diagnoses included,

but were not limited to dementia, anxiety and

depression.


assessment, dated 6/6/18, indicated Resident D


score of 5, severe cognitive impairment and was

receiving antidepressant and antianxiety

medications with no GDR (gradual dose

reduction) dates.

A care plan, revised on 6/8/18, indicated Resident

D was at risk for decline in mood due to diagnosis

of depression and anxiety and she was taking

both antidepressants and antianxiety medications.

There were not no targeted behaviors or

individualized interventions present for anxiety

symptoms.


indicated Resident D had an order for Ativan

(antianxiety) 0.5 mg (milligrams) every eight

(8)hours for anxiety with a start date of 8/28/17

and Lexapro 10 mg at bedtime for depression with

a start date of 3/21/17.

The Documentation Survey Report, dated July

2018, indicated Resident D had behaviors of being

combative during care, searching for family

members and wandering on and off the unit with

no documentation of interventions that were

efficacy and updated/changed as

needed. Medications will be

reduced per CMS guidelines. If a

GDR is clinically contraindicated

documentation indicating a

rationale will be in the resident’s

chart. GDR tracking will be

maintained per policy.






into place; and


behavior tracking results, progress

notes, GDR history, and

psychotherapeutic medications on

a minimum of 5 residents weekly

x 4, then 10 residents monthly

x11 months. GDR tracking will be

maintained for each resident on

psychotherapeutic medications.

















08/29/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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155153 08/06/2018

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20531 DARDEN RD

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attempted.



depression and anxiety should be in separate

plans of care and plan of care should contain

targeted behaviors and individualized

interventions. The DON indicated behaviors

should be tracked daily to included interventions

that were attempted with effectiveness.


DON indicated a GRD should have been

attempted since the start date of the medications.

3. The clinical record for Resident E was reviewed


but were not limited to, dementia, anxiety and

depression.


assessment, dated 6/5/18, indicated Resident E


score of 12, moderate cognitive impairment, and

was receiving antipsychotic and antidepressant

medication.


indicated Resident E had an order for Seroquel 25

mg (milligrams) at bedtime related to Parkinson's

Disease.

A care plan, dated 6/18/18, indicated Resident E

uses antipsychotic medications related to the

disease process of Parkinson's.


individualized interventions present for the use of

antipsychotic medications.


correction date.

9/5/18





08/29/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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155153 08/06/2018

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20531 DARDEN RD

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DON (Director of Nursing) indicated a diagnosis

of Parkinson's was not an appropriate diagnosis

for antipsychotic medication use.

On 8/6/18 at 11:45 A.M., the DON provided the

Behavioral Health Services policy, dated 2018, and

indicated this was the policy currently be used by

the facility. The policy indicated the plan of care

should be person-centered, provide for

meaningful activities which promote engagement

and positive, meaningful relationships, reflect

resident's goals for acre, account for the resident's

experiences and preferences and maximize the

resident's dignity, autonomy, privacy,

socialization, independence and safety. The

facility staff should receive education to ensure

appropriate competencies and skills sets for

meeting the behavioral health needs of residents.

Behavioral health care and services should be

provided in an environment that promotes

emotional and psychosocial well being, supports

each resident's need and includes individualized

approaches to care.

On 8/6/18 at 11:45 A.M., the DON provided the

Gradual Dose Reduction on Psychotropic Drugs,

dated 2018, and indicated this was the policy

currently being used by the facility. The policy

indicated reducing the need for and maximuzung

the effectiveness of medications shall be

considered for all residents who use psychotropic

drugs. For any individual who is recieving a

psychotropic medication to treat expressions or

indications of distress related to dementia, the

GDR may be considered clinically contraindicated

for reasons that include, but that are not limited

to, target symtpoms return after most recent GDR

within facility and there is documented clinical

rationale.





08/29/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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B. WING

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155153 08/06/2018

HEALTHWIN

20531 DARDEN RD

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3.1-48(a)(3)

3.1-48(a)(4)

483.60(i)(1)(2)

Food

Procurement,Store/Prepare/Serve-Sanitary

§483.60(i) Food safety requirements.

The facility must -

§483.60(i)(1) - Procure food from sources

approved or considered satisfactory by

federal, state or local authorities.

(i) This may include food items obtained

directly from local producers, subject to

applicable State and local laws or

regulations.

(ii) This provision does not prohibit or prevent

facilities from using produce grown in facility

gardens, subject to compliance with

applicable safe growing and food-handling

practices.

(iii) This provision does not preclude residents

from consuming foods not procured by the

facility.

§483.60(i)(2) - Store, prepare, distribute and

serve food in accordance with professional

standards for food service safety.

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Based on observation, interview and record

review, the facility failed to ensure appropriate

hand hygiene was completed during meal service,

thumbs did not come into contact with eating

surfaces, and gloves were used appropriately for 2

of 6 dining rooms observed. (Main and

Specialized Dining Rooms)

Findings include:

During an observation of the main dining room,


consideration for desk review

for all citations.

It is the practice of Healthwin to

store, prepare, distribute, and

serve food in accordance with

professional standards for food

service safety



09/05/2018 12:00:00AM





08/29/2018PRINTED:

FORM APPROVED

OMB NO. 0938-039




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155153 08/06/2018

HEALTHWIN

20531 DARDEN RD

00

on 07/31/18 at 11:18 AM, HA 3 (Hospitality

Associate) pulled up her socks, wiped her hands

on pants, and served 3 plates. Thumb was placed

on the eating surface of one plate. She took a

dessert plate to a table and placed it in front of a

resident, then took the same plate to another table

and gave it to a different resident. She served 2

more plates, pulled up her pants, served jello,

threw away trash from a table and served 4 more

plates. She reached into her back pockets and

served 2 more plates. No hand washing was

observed at any time.

During an observation of the specialized dining

room, on 07/31/18 at 12:25 PM, RN 2 (Registered

Nurse) put on gloves, placed a clothing protector

on a resident, moved a wheelchair, poured drinks,

touched a resident's hand, then back to serving

drinks. She then touched another resident's hand,

placed a napkin in a resident's lap, proceeded to

serve drinks, removed silverware and placed in a

resident's food. She removed her gloves and

washed hands for 15 seconds. No glove change

or additional hand hygiene occurred.

During an interview, on 08/06/18 at 12:09 PM, the

DON (Director of Nursing) indicated none of the

things observed should have occurred.

A policy was provided by the DON (Director of

Nursing) on 08/06/18 at 9:30 AM, titled

"Handwashing Guidelines-Dietary Employees",

undated, and indicated this was the policy

currently used by the facility. The policy

indicated "...Dietary employees shall keep their

hands and exposed portions of their arms

clean...shall clean their hands...immediately before

engaging in food preparation...after having

touched anything unsanitary. c. After hands have

touched bare human body parts...after engaging



practice;

CMS regulations and Dining

Observation Critical Pathway

reviewed. Hospitality Aide and RN

inserviced with return

demonstration on handwashing

and food handling.

All dietary staff were also informed

with education ongoing through

September 5th, 2018.






be taken;

All resident that consume food by

mouth have the potential to be

affected.






Inservices for Dietary and Nursing

departments conducted by dietary

management/staff

development/designee

8/20/18-9/5/18.










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OMB NO. 0938-039




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155153 08/06/2018

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in any activity that may contaminate the hands...."

A policy was provided by the DON (Director of

Nursing) on 08/06/18 at 9:30 AM, titled "Food

Handling Principles for Infection Control",

undated, and indicated this was the policy

currently used by the facility. The policy

indicated "...Wash hands prior to preparing and

serving meals...Avoid touching hair, face or other

body parts while serving food...Do not touch the

ends of utensils (e.g., tips of spoons, or drinking

edge of cups)...Do not touch the eating surfaces

of plates...."

3.1-21(h)(3)

into place; and

Dietary Manager or designee

dining observation daily for 30

days; one audit weekly for 6

months;

monthly for 5 months

Results will be reviewed at QA

meetings














correction date.

9/5/18


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